Basic Information
| Provider Information | |||||||||
| NPI: | 1699082032 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACT MEDICAL GROUP, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 696 | ||||||||
| Address2: | |||||||||
| City: | HAMPSTEAD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284430696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107916767 | ||||||||
| FaxNumber: | 9107916890 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 ORANGE ST | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288012328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282390156 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2010 | ||||||||
| LastUpdateDate: | 10/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | BEEKMAN | ||||||||
| AuthorizedOfficialFirstName: | ERINN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9107916767 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 87550 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 5914040 | 05 | NC | MEDICAID |